Fatal

CHAPTER 14

It was after ten in the morning when Matt finally felt comfortable leaving Lewis with his brothers. Frank seemed naturally to assume the role of chief caregiver, and compared to Lyle and Kyle, he was Matt's odds-on choice for the job. Matt gave him a set of wound-care instructions and general observations to make, begged him to bring Lewis into the hospital if there was any change for the worse, and promised to return as soon as his workload permitted. Then he revved up the Vulcan and headed back toward his place to shower, change, and call Mae.

"Dr. Rutledge, I was just about to send the police out to your house," she said.

"Sorry. I went for a long ride last night and ended up sleeping under the stars."

"There were no stars last night, sir," Mae replied in a syrupy drawl. "No need to waste the truth on me. I'm your biggest fan, and I'm going to believe whatever you say."

"That's just as well, Mae. Believe me. Everything okay?"

"No, everything is not okay. You are on backup for the ER today and they've been trying to reach you for an hour."

"Lord."

"Pardon?"

"I said, I'll call them right away."

"The nurse said something about a fifty-year-old man from Hawleyville with diarrhea and a fever and no doctor."

"He's in luck. I was voted the fever/diarrhea prize at Harvard. Is the office okay?"

"The office is fine… Are you?"

"What are you, some kind of witch?"

"There are those who might say so. Anything I can do?"

"Not at the moment. Just keep the afternoon as light as possible."

"I'll do my best."

Matt called the ER and gave several holding orders — diagnostic and therapeutic — on a farmer who sounded as if he might have contracted a bacterial infection in his intestine, possibly salmonella or shigella. Then he stripped in his bedroom, kicked his filthy clothes under a chair, and basted himself in a shower as hot as he could stand. The scratches and nicks on his face weren't as bad as he'd anticipated, but it took several minutes of scrubbing before he realized that the blackness enveloping his eyes had nothing to do with Lewis's camouflage potion, and wasn't going to wash away.

As he was toweling off, he glanced over at the book on the toilet tank: Manual of Medical and Surgical Field Emergencies. It would probably be a lifetime before he ever needed to perform one of the procedures again. Still… He briefly flipped through the pages and then moved the book to the more prestigious location on his bedside table.

The farmer with fever and diarrhea was dehydrated and in moderate abdominal discomfort. Matt evaluated him, wrote a set of orders, and dictated his lengthy admission note. He was praying for an easy day, but that was simply not happening. Twenty minutes later, a ninety-year-old woman arrived by ambulance, sent in from one of the nursing homes with a dense stroke, unable to move her right side or speak. It was a medical and ethical nightmare, and of course her primary-care doc was on vacation. Matt wondered about the wisdom of treating her at all. He stood at her bedside, cradling her gnarled hand in his, looking into her glazed-over eyes, but receiving no definite message. His mother was much younger than this woman and wasn't nearly at this point yet, but her Alzheimer's was advancing steadily, and before too many more years, he would be facing constant questions of what was cruel treatment and what was not. But today was today for his mother, just as it was for this poor woman. Sighing, he picked up her chart and wrote orders for hydration, diagnostic studies, and a stat neurology consult. He would need more information about her, much more, before he put on his long white robes and began playing God.

By the time he had completed his second lengthy admission dictation of the day, seen several scheduled appointments in the office, and made rounds on his three other hospitalized patients, the afternoon was fading. Back in the ER, he consulted a list he had compiled of equipment and medications to be "appropriated" from the hospital for Lewis. He had just put together a real chest tube and drainage system when an ambulance EMT, who had been drinking coffee in the lounge, hurried out to him. His name was Gary Lydon. He was earnest, baby-faced, and not much more than twenty.

"Dr. Rutledge," he said breathlessly, "dispatch just radioed. The police just got a call from a motorist on Wells Road. Apparently some kids just dove down and pulled a woman up from the bottom of Crystal Lake. They were fishing beneath Niles Ledge when she tumbled off it from right above them, and just sank."

"She's alive?"

"So they say."

Kirsten Langham, the second EMT, joined them. She had a bit more experience than Gary, but was still fairly green. It wasn't like Rescue to put together such a team. Matt accompanied the pair out to their ambulance.

"How long was she under?" he asked.

"Dispatch didn't say. There's a problem, though."

"What?"

"Rick Wise is the paramedic on this shift and he's off on Harlan Road picking up a motorcyclist. If this woman needs to be intubated, neither me nor Kirsten is certified to do it."

Crystal Lake near Wells Road. Matt estimated that by the time the two EMTs got the woman out of the woods, into the ambulance, and back to the hospital, a half an hour would have passed, maybe even more. If she needed a breathing tube — and unless she was wide-awake and talking sensibly, she did — it should be done as soon as they reached her.

"Hang on for just a minute," he said. "I'm going with you."

"Bless you, Doc," Gary said. "I'll save you a seat up front."

"No, I want to be in back to check the equipment."

"Kirsten'll help you. I'll drive."

Matt raced into the ER, told the nurses where he'd be, and then hustled into the rear cabin of the ambulance. The return trip to the Slocumbs' farm was just going to have to wait. Hopefully, Lewis was still stable. If not, Frank Slocumb had better have the courage and good sense to bring him in.

Siren blaring, the ride to the spot on Wells Road took ten minutes. An empty Belinda PD black-and-white was parked on the soft shoulder, flashers on. Gary Lydon drove past the cruiser before pulling over beside a narrow trail that Matt knew led into Niles Ledge. He had prepared the large plastic crash case with all the equipment he might need to intubate. Hauling the case, he raced through the woods, sensing a powerful, unpleasant feeling of deja vu. What Lewis and he had been through already seemed like a year ago. After a quarter of a mile, the winding track split — one path to the top of the ledge and one down to the water.

"Take the right fork," he hollered, on the off chance that the EMTs hadn't grown up in the area.

"We hear you," Gary called back.

The scene under the massive ledge was impressive. Several fishing skiffs had tied up along the shore, and their occupants had joined two uniformed policemen and two teenage boys. Crystal Lake was long and fairly large. The ledge, situated in a broad cove near the south end, was difficult to reach, but offered diving into fifteen feet of water, and around it, some decent fishing as well. The two boys, still wearing their waterlogged jeans but no shirts or shoes, stood off to the side. A policeman knelt beside a supine woman, alternately giving her a mouth-to-mouth breath and pausing to watch her take an occasional shallow breath on her own.

"These boys here are heroes, Doc," the standing policeman said proudly. "They saved her."

But — what's left? Matt wondered as he knelt beside the other cop.

"Officer Gibbons, sir," the young policeman said. "I think we've met before."

"What's the story?" Matt asked, already into his examination.

The woman, thin, white, in her thirties, was unconscious and breathing ineffectually. Her dark hair was matted to her forehead. Her lips were purple. The officer was right to keep breathing for her, and Matt told him to continue. Her pupils were midposition, but did not react to a flash from his penlight — either the result of a technically limited exam, or a very grim sign. She wore jeans, sneakers, and a black T-shirt with a wavy musical scale on the front, and had a raw bruise and abrasion just above her left eye. There was also a long laceration, more of a gouge, along the hairline, just above her right temple.

The EMTs arrived and Matt instructed them to begin breathing her with a bag as soon as they could.

"These boys were fishin' here," the standing officer said, "when suddenly this lady came plungin' off the ledge from up above them. One of them, Percy Newley's boy Harris, swears he heard something like a gunshot just before she flew past him and into the water."

"Did they get her up on the first try?" Matt asked, listening to her chest with his stethoscope as he was speaking.

"Excuse me?"

"Percy's boy and his friend, did they haul her up on the first dive?"

The officer's sheepish expression said that he had just grasped the significance of the question he clearly hadn't asked.

"Harris, how many tries did it take for you to pull this woman off the bottom?"

"Two. Michael tried first, then we did it together. We hauled her up by the hair."

"Thank you," Matt said, already preparing for an intubation.

He estimated the submersion time at two minutes and hoped he wasn't giving the boys too much credit. Meanwhile, Gary was setting the triangular cup of the breathing bag in place over the woman's mouth and nose while Kirsten was inserting an IV. After the breathing tube was in place, the cup would be set aside and the bag connected directly to the tube.

"Normal saline?" Kirsten asked.

"Exactly," Matt said. "You're all doing great. Thanks to these heroes and the good mouth-to-mouth technique they did, this lady's going to make it. But she still needs our help. I'm going to put a breathing tube in so we can get some concentrated oxygen into her lungs. Let's put her on the stretcher, Gary, and lift her up. I'd rather work with a little elevation than stretched out on my belly with her flat on the ground."

In the hospital, the anesthesiologists were the royalty of intubation, having honed their skills hundreds of times in the operating room. During one of his residency electives, Matt had chosen anesthesia and "tubed" dozens of cases under their guidance. Over the years that followed, he had multiple reasons to be grateful for every one of those opportunities. The main rule he had learned was that if the caregiver performing the procedure wasn't absolutely comfortable, physically and mentally, the chances of a failed intubation were greatly increased. The most common disasters were intubating the esophagus instead of the trachea, thereby filling the stomach with air; tearing the tissues of the throat and causing bleeding, which made subsequent attempts that much more difficult; damaging the vocal cords by forcing the tube down without adequate visualization; and finally, inserting the tube too deeply and occluding one of the two main bronchial tubes.

Matt now did what had been taught to him and what subsequently he had taught to many students and paramedics — he took an extra few seconds to position his new patient and compose himself before proceeding. With the woman on her back on the stretcher, he tilted her head slightly downward, straightening her neck. Gary Lydon knelt beside him to hold her head steady in that position. Physically settled on one knee, and as confident as he could be given the circumstances, Matt slid a curved, lighted laryngoscope blade along the woman's tongue and pulled the blade straight up toward her chin. All he could see was lake water, welling up from her lungs. Trouble — maybe big trouble. In the ER there would have been suction to clear her airway. Not here. A blind thrust with the semi-rigid tube was possible, but treacherous. Doing so had to be a last resort.

Easy, now, easy.

The woman's color remained poor. Brain cells were being compromised every second. Soon, they would begin to die.

Come on, Rutledge. Stay cool and don't panic. You can do this… You… can… do… this.

Matt took a deep, calming breath, grasped the handle of the scope tighter, and pulled the blade upward another eighth of an inch. The move nudged the victim's tongue out of the way even more and lifted her epiglottis — the flap that protected the lungs from aspirating food or drink. The slight adjustment caused the pool of water to recede just enough to expose the two silvery half-moons of her vocal cords.

Yes!

Matt smoothly slid the tube between the cords.

"We're in," he said, trying for some matter-of-factness but missing badly.

There was audible relief from both EMTs and the police.

"Nice going," one of them said.

Matt used a large syringe to blow up the balloon fixed around the end of the tube, sealing it in place and preventing air from escaping around it. Kirsten Langham quickly attached the black latex bag to the tube and connected it to oxygen. In seconds, the mottled duskiness of the woman's complexion began to improve. She was almost certainly going to make it. How much of her brain would make it, too, remained to be seen.

Matt handled the breathing bag as the troupe awkwardly retraced their steps, pushing the stretcher along the path back to the ambulance. While the woman was being lifted into the back, Matt took the two teens aside.

"You guys did one heck of a job. In all likelihood, you saved this woman's life."

"Lucky we was there," one of them said.

"I'll say. You're Harris?"

"I'm Michael. He's Harris."

"Got it. Two things. First, tell me again. You were fishing and she fell into the water right in front of you."

"Yes."

"And sank?"

"She might of stayed on the top for a second or two," Michael said, "but otherwise that's the way it happened. I got down ta her, but I couldn't get a grip afore I ran out of breath. Then we did it together an' brought her up by the hair."

Two minutes, minimum, Matt estimated again. Four maximum, depending on when they started breathing for her and how well they did it.

"And you did mouth-to-mouth?"

"Harris did. I screamed for help."

"Harris, did you hold her nose closed?"

"I did, sir. And I tipped her head back, too."

"Where did you learn how to do mouth-to-mouth?"

"They taught us in Health, sir. We used a dummy to practice."

"Well, we sure are glad you were paying attention in that class," Matt said. "Now, about those gunshots."

"They weren't shots," Michael said. "They were too soft. They were branches cracking, probably. Maybe a car backfirin' out ta the road."

"Were, too, gunshots," Harris insisted. "Michael, I'm telling you, pistols don't sound the same as backfirin'. There were two shots, maybe three."

"Ready," Gary called out from the rear of the ambulance. "Kirsten's going to bag her with you. I'll drive."

"You guys did great," Matt said again. "Lots of people, doctors included, sometimes think they saved someone's life, when the truth is, they might not have. Take it from me, you two really did it."

He jumped into the ambulance and waved to the boys as Gary closed the door. Then he took a seat on the bench opposite from the EMT and, for the first time, took a careful look at the woman who had come so close to dying beneath Niles Ledge.

She was still unconscious. The swelling above her left eye was pronounced and beginning to discolor. But to Matt's touch, there was no evidence for a depressed skull fracture beneath the bruise. The linear gouge above her right temple certainly could have been from a gunshot. There were also scratches on her cheeks and chin, similar to those Matt had sustained just half a day ago. It wasn't a stretch to imagine her terrified, charging through the dense woods with someone shooting at her.

He separated her eyelids and used his penlight to check her pupils' response to light again. This time the results were different.

"Pupils are both reacting," he announced to the EMT.

"Great," Kirsten said. "Her oxygen sat is ninety-seven."

"Decent enough. I can't say why, but she just doesn't seem that deep to me."

"I know what you mean. She's sort of begun chewing on the tube a little."

Matt brushed her sodden hair from her forehead. Her face, distorted some by the breathing tube, still had a peaceful, gentle quality to it — pale, unlined brow… high cheekbones… wide, almond-shaped eyes. He lifted her limp hand and set it on his. Her fingers were long and slender, nails cut short. If there was polish on them, it was clear. There was a gold claddagh friendship ring — two hands supporting a heart — on her right fourth finger, and a single gold bangle on her left wrist. No other jewelry. Her palms were soft without a hint of callus, but there was a fullness to the muscles. Matt imagined the hands playing piano or writing or throwing clay pots — something manual and artistic.

Come on, you, he urged silently, wake up!

The mobile MRI facility that served the region was currently in its two-month rotation at Hastings Hospital, twenty-five miles away. Montgomery County, though, did have a CT scanner, which for blunt head trauma was nearly as definitive. Matt radioed ahead and asked that the room be reserved in one hour. He also asked the nursing supervisor to call the Belinda Police Department and request that an officer come down to the ER to begin investigation of a possible shooting, and also to try and determine the identity of their patient. He wondered as he rang off whether or not the powers at BC amp;C had filed any complaint with the police against him.

Patient saved, doctor arrested.

The sort of news a small town loves.

The ER crew was waiting for them as they backed into the ambulance bay. For the next fifteen minutes, Matt was a secondary player. The nurses and respiratory technologist became the major caregivers while the phlebotomist from the lab and the tech from radiology spearheaded the gathering of diagnostic information. Their comatose Jane Doe was lifted from the stretcher to an ER bed, stripped down, and covered in a johnny and a sheet. Her IV and monitor lines were quickly transferred to hospital equipment. A catheter was placed in her bladder to keep close track of hydration and urinary output, and she was hooked up to a ventilator. Next, a portable chest X ray and skull film were taken.

Finally, the crew stepped aside and Matt resumed his position at the bedside. This time, his examination would be more detailed, including the critical visualization by ophthalmoscope of the retinas in the back of Jane Doe's eyes. He was relieved to see pulsation in the veins there, as well as a sharpness to the margins of the optic nerves. Loss of either would be a grave sign, indicating significant brain swelling from trauma and/or prolonged lack of oxygen.

"So, Dr. Rutledge, I understand you called?"

Grimes.

Matt turned slowly to face the Belinda police chief. The two of them had had some conflicts over the years, usually surrounding some action or other Matt was running against BC amp;C. Matt also complained more than once of being harassed with tickets — parking and speeding. Grimes was ex-military and kept the town on a pretty short leash. A displaced northerner with some sort of degree in criminal justice, he had adopted something of a mountain accent. He was divorced, with a kid in Florida someplace that Matt heard he never saw. Their contrast in styles alone would have strained their relationship, but Grimes's connection with Armand Stevenson and the other directors of the mine all but sealed their enmity.

Over the years, the police chief had appointed himself as a one-man watchdog committee to step in whenever Matt didn't have an appropriate permit or was posting notices against a town ordinance. Matt suspected Grimes or his lackeys were behind the disappearance of most if not all of the magenta fliers.

"I just asked for a policeman," Matt said, "not the policeman."

"You're a very important person to us," Grimes replied, smiling civilly. "What do you have?"

Matt gestured to his patient. At the sight of her, Grimes's lips tightened noticeably.

"This woman plunged off Niles Ledge and into the lake," Matt said. "One of the two kids who rescued her said he heard several shots. The other kid doesn't think so. She's got a big bruise over her eye. That may be why she's unconscious, but she also has a scalp wound that could be from a gunshot. I'm legally required to report any possible shooting."

"Thanks for telling me that, Doctor. From time to time I forget some of the laws. How long was she underwater?"

"I estimate two minutes minimum, four maximum. She had no ID, so in addition to reporting the possible bullet wound, I hoped maybe you could find out who she is."

Grimes stepped forward, set his hands on the bed rail, and gazed down at the woman.

"Her name is Nikki Solari," he said flatly. "She drove down from Boston to attend Kathy Wilson's memorial service earlier today. I spent some time talking with her there. Wilson was her roommate. You know who she was?"

"I know about her, and I've heard some of her music, but I didn't know her personally."

"Well, she was hit by a truck in Boston. Died instantly."

"I heard something about it from Hal Sawyer. Apparently he knew the family and Kathy."

"Yeah, he was at the service. Well, this woman played fiddle in Kathy Wilson's bluegrass band."

Matt decided that playing fiddle was close enough to pianist. He was mentally patting himself on the back for astutely concluding that Nikki Solari's hands were those of an artist, when Grimes added, "She only played music as a hobby. She's actually a pathologist — a coroner up in Boston. Spends her time working up to her elbows in gore and guts."

Matt immediately stopped the patting.

"What do you think about that wound above her ear?" he asked.

Grimes studied it.

"I guess it could be from a bullet," he said. "But it could just as easily be from something else, like a broken branch."

"Well, we'll find out for sure when she wakes up."

Grimes suddenly whirled to face him.

"You just make sure that she does!" he snapped.